Failure to Provide Timely Meals and Substantial Snacks Between Dinner and Breakfast
Penalty
Summary
The facility failed to ensure that meals were served within the required 14-hour window for four residents with various medical conditions, including anxiety, adjustment disorder, epilepsy, Type 2 diabetes mellitus, hypertension, dysphagia, gastro-esophageal reflux disease, anemia, localized edema, and orthostatic hypotension. According to the facility's meal schedule, dinner was served at 4:45 PM and breakfast at 7:45 AM, resulting in a 15-hour gap between meals. Clinical record reviews and resident interviews confirmed that these residents did not receive a substantial snack between dinner and breakfast, with some reporting that the snack cart was not consistently available or only offered limited options such as crackers. Further observations and staff interviews revealed that the snack carts, which were supposed to be provided three times daily, typically contained only crackers, apple sauce, and oatmeal cookies. Residents reported that requests for more substantial snacks, such as sandwiches or peanut butter and jelly, were often met with resistance from staff or not fulfilled. The nourishment room observation supported these claims, showing a limited variety of snacks available. These findings indicate that the facility did not meet the nutritional needs and preferences of residents who required or requested food outside of scheduled meal times.